Endoscopic Third Ventriculostomy Using Penumbra Artemis™ Neuro Evacuation Device: Technical Case Report and Operative Video.

Endoscopic third ventriculostomy (ETV) is an effective cerebrospinal fluid diversion procedure but can be complicated by the presence of a high-riding basilar artery (BA). A 70-year-old female presented with obstructive hydrocephalus caused by melanoma metastatic to the brainstem in the setting of a high-riding BA. ETV was successfully performed using the Penumbra Artemis™ Neuro evacuation device (Artemis; Penumbra Inc, Alameda, CA, USA) to minimize the risk of injury to the BA. This is to our knowledge the first known Artemis-assisted ETV reported in the English literature, which may reduce the risk of BA injury in selected patients. Further characterization of the benefits and limitations of this procedure is needed.

CBF oscillations induced by trigeminal nerve stimulation protect the pericontusional penumbra in traumatic brain injury complicated by hemorrhagic shock.

Traumatic peri-contusional penumbra represents crucial targets for therapeutic interventions after traumatic brain injury (TBI). Current resuscitative approaches may not adequately alleviate impaired cerebral microcirculation and, hence, compromise oxygen delivery to peri-contusional areas. Low-frequency oscillations in cerebral blood flow (CBF) may improve cerebral oxygenation in the setting of oxygen deprivation. However, no method has been reported to induce controllable oscillations in CBF and it hasn't been applied as a therapeutic strategy. Electrical stimulation of the trigeminal nerve (TNS) plays a pivotal role in modulating cerebrovascular tone and cerebral perfusion. We hypothesized that TNS can modulate CBF at the targeted frequency band via the trigemino-cerebrovascular network, and TNS-induced CBF oscillations would improve cerebral oxygenation in peri-contusional areas. In a rat model of TBI complicated by hemorrhagic shock, TNS-induced CBF oscillations conferred significant preservation of peri-contusional tissues leading to reduced lesion volume, attenuated hypoxic injury and neuroinflammation, increased eNOS expression, improved neurological recovery and better 10-day survival rate, despite not significantly increasing CBF as compared with those in immediate and delayed resuscitation animals. Our findings indicate that low-frequency CBF oscillations enhance cerebral oxygenation in peri-contusional areas, and play a more significant protective role than improvements in non-oscillatory cerebral perfusion or volume expansion alone.

Sphenoid Wing Meningioma with Surgical Revascularization of an Injured Anterior Temporal Artery.

A 79-year-old woman presented to the emergency department following multiple falls in the previous week. Her past medical history was unremarkable except for chronic obstructive pulmonary disease. She was neurologically intact on arrival with normal laboratory data. Brain imaging revealed a right-sided sphenoid wing meningioma with considerable edema around it. Owing to her cognitive decline and recent symptoms, it was decided to proceed with surgical resection of the lesion. Considering her age and underlying disease, we planned to avoid probable complications of an aggressive resection. She underwent preoperative transarterial embolization with particles. In the supine position, a right pterional craniotomy with orbital extension was performed followed by tumor resection under microscopic magnification. One of the branches of the middle cerebral artery was engulfed by the tumor and could not be separated; therefore, the artery was cut to resect the tumor and then mobilized and reanastomosed under microscope. Doppler probe confirmed patency of the anastomosis. The patient recovered well from the surgery, experienced an uneventful hospital stay, and was discharged on postoperative day 10 after completely controlling her chronic obstructive pulmonary disease. Postoperative imaging did not show any signs of infarction, and the revascularized artery was patent on postoperative computed tomography angiography (Video 1).